NPIMap

Organization Active NPI

Mille Lacs Health System

  • Rural Health Clinic/Center
  • Isle, MN
National Provider Identifier
1497917587
Registry record updated May 13, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MILLE LACS HEALTH SYSTEM
Practice address
375 W Isle St
Isle, MN 56342-2640
Phone
(320) 676-3661
Fax
(320) 676-4011
NPI assigned
Jun 30, 2008
Organization subpart
Yes
Parent organization
MILLE LACS HEALTH SYSTEMAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 13, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. John W Unzen
Title
Cfo
Phone
(320) 532-2581

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
ChiropractorGroup: 193200000X MULTI-SPECIALTY GROUP 111N00000X
Diabetes Educator Registered NurseGroup: 193200000X MULTI-SPECIALTY GROUP 163WD0400X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary
Medical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AM0700X

Addresses

Primary practice location

375 W Isle St
Isle, MN 56342-2640

Mailing address

200 Elm St N
PO Box a
Onamia, MN 56359-7901
Phone (320) 532-3154

Other identifiers 3

IdentifierTypeStateIssuer
33523MIOtherMNBLUE CROSS BLUE SHIELD MINNESOTA
566354700MedicaidMN
115807OtherMNUCARE MINNESOTA

Other names 1

  • Mille Lacs Family Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040204000052 MN Part B Supplier - Clinic/Group Practice 4789577834 Receives reassigned benefits from 133 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Milaca, MN; Princeton, MN; Onamia, MN; Isle, MN; Hillman, MN; Garrison, MN
O20090114000606 MN Part A Provider - Rural Health Clinic 4789577834 Practice locations: Isle, MN

Rural health clinic certification: CCN 243975

Legal name
MILLE LACS HEALTH SYSTEM
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 1, 1990
Last certification
Aug 18, 2015
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jun 20, 1990 in MN
Enrollment address
375 W Isle St
Isle, MN 56342-2640
Related CCNs
241356

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D0651637Mille Lacs Health System - Isle Clinic375 West Isle Street, Isle, MN 56342Certificate of waiverJun 30, 2028

National Provider Directory

National Provider Directory
Part of
Mille Lacs Family Clini

Locations

200 Elm St N
Onamia, MN 56359
Phone (320) 532-2750

Ownership & related parties

All disclosed owners & managing parties 14

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Robert Dubbs Individual Corporate Director Jan 8, 2015
Rebecca K Fossand Individual Corporate Director Jan 4, 2016
Amy S Ninham Individual W-2 Managing EmployeeCfo Mar 10, 2025
Andrew Knutson Individual Corporate OfficerCeo Jan 27, 2025
W-2 Managing EmployeeCeo Jan 27, 2025
Robert a Athman Individual Corporate DirectorBoard Member Jan 1, 2025
Jean M Stafford Individual Corporate Director Jan 13, 2022
Roger W Tramm Individual Corporate DirectorBoard Member Jan 1, 2023
Mille Lacs Health System Organization, Onamia, MN Operational/Managerial Control Sep 10, 2008
Anthony Hass Individual Corporate DirectorBoard Member Jan 1, 2023
Tracy L Sam Individual Corporate DirectorBoard Member Jan 1, 2024
Louis P Gravel Individual Corporate Director Jan 12, 2012
Patti J Hook Individual Corporate Director Sep 1, 1991
Arden Virnig Individual Corporate Director Sep 10, 2008
Dennis Burr Individual Corporate Director Jan 8, 2015

Owners & managing parties with NPI records 12

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Cura of OnamiaOnamia, MN, CCN 245127 Skilled nursing facility Adp of the SNF Jul 22, 2002
Mille Lacs Health SystemOnamia, MN, CCN 241588 Hospice Operational/Managerial Control Jun 17, 2009
Mille Lacs Health SystemOnamia, MN, CCN 243976 Rural health clinic Operational/Managerial Control Sep 9, 2008

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 54

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 54

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1214784000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1368403200000",
    "number": "1497917587",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 ELM ST N",
            "address_2": "PO BOX A",
            "city": "ONAMIA",
            "state": "MN",
            "postal_code": "563597901",
            "telephone_number": "320-532-3154",
            "fax_number": "320-532-3111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "375 W ISLE ST",
            "city": "ISLE",
            "state": "MN",
            "postal_code": "563422640",
            "telephone_number": "320-676-3661",
            "fax_number": "320-676-4011"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MILLE LACS HEALTH SYSTEM",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MILLE LACS HEALTH SYSTEM",
        "enumeration_date": "2008-06-30",
        "last_updated": "2013-05-13",
        "status": "A",
        "authorized_official_last_name": "UNZEN",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "320-532-2581",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "163WD0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Registered Nurse, Diabetes Educator",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD MINNESOTA",
            "identifier": "33523MI",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "566354700",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE MINNESOTA",
            "identifier": "115807",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mille Lacs Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Isle, MN

Sources for this page

Verify at the official NPI Registry.